Niagara, WI

Maryhill Manor

5-star overall rating with 3-star inspections with $50,606 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

501 Madison Ave, Niagara, WI

(715) 251-3172

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

50

Certified beds

Average residents

47

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1990-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.01

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

0.25

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.89

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

4.14

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.26

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.73

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.58

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

1.14

CMS adjusted RN staffing hours

Adjusted total hours

4.67

CMS adjusted total nurse staffing hours

Case-mix index

1.21

Higher values indicate more complex resident acuity

RN turnover

27%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

41%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,295

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

45.01

Composite VBP score used to determine payment impact.

Payment multiplier

0.9982

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.70

Performance 19.25% · Measure score 4.70 · Achievement 4.70 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

3.46

Performance 6.80% · Measure score 3.46 · Achievement 3.46 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

5.39

Baseline 46.51% · Performance 41.67% · Measure score 5.39 · Achievement 5.39 · Improvement 1.74

Adjusted total nurse staffing

4.45

Baseline 3.59 hours · Performance 4.34 hours · Measure score 4.45 · Achievement 4.45 · Improvement 2.94

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.81%	10.72% 0.9 pts better	No Different than the National Rate · Eligible stays 53 · Observed rate 3.77% · Lower 95% interval 6.18%
Discharge to community	46.23%	50.57% 4.3 pts worse	No Different than the National Rate · Eligible stays 48 · Observed rate 45.83% · Lower 95% interval 36.72%
Medicare spending per beneficiary	1.4	1.02 0.4 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 29 · Denominator 29
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 29
Discharge self-care score	39.13%	53.69% 14.6 pts worse	Numerator 9 · Denominator 23
Discharge mobility score	34.78%	50.94% 16.2 pts worse	Numerator 8 · Denominator 23
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 29 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.8%	7.12% 0.3 pts better	No Different than the National Rate · Eligible stays 34 · Observed rate 2.94% · Lower 95% interval 3.3%
Staff COVID-19 vaccination coverage	10.99%	8.2% 2.8 pts better	Numerator 10 · Denominator 91
Staff flu vaccination coverage	56.7%	42% 14.7 pts better	Numerator 55 · Denominator 97
Discharge function score	34.78%	56.45% 21.7 pts worse	Numerator 8 · Denominator 23
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.8	1.6 0.8 pts better	1.9 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.5 · Expected 1.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	2.2 1 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.2 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	95.7% 4.3 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.4%	3.2% 0.2 pts worse	3.3% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.3% · Q3 4.7% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.6%	5.0% 2.4 pts better	11.4% 8.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 2.9% · Q4 5.3% · 4Q avg 2.6%
Percentage of long-stay residents who lose too much weight	5.5%	4.9% 0.6 pts worse	5.4% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.0% · Q3 7.0% · Q4 2.4% · 4Q avg 5.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	8.7%	16.6% 7.9 pts better	19.6% 10.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 6.7% · Q3 11.6% · Q4 9.3% · 4Q avg 8.7%
Percentage of long-stay residents who received an antipsychotic medication	7.1%	16.7% 9.6 pts better	16.7% 9.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.5% · Q3 10.3% · Q4 5.0% · 4Q avg 7.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	16.8%	21.1% 4.3 pts better	16.3% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 26.9% · Q3 7.5% · Q4 6.7% · 4Q avg 16.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.5%	17.3% 3.8 pts better	14.9% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 17.1% · Q3 7.7% · Q4 7.7% · 4Q avg 13.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	2.3% 2.3 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	6.6%	3.0% 3.6 pts worse	1.7% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 4.5% · Q3 7.0% · Q4 7.3% · 4Q avg 6.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.4%	25.5% 7.1 pts better	19.8% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 20.3% · Q3 19.8% · Q4 8.0% · 4Q avg 18.4%
Percentage of long-stay residents with pressure ulcers	1.2%	5.5% 4.3 pts better	5.1% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.5% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	86.8% 13.2 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0%
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-06 · Fire 2024-11-06

4 health deficiencies

Top issue: Infection Control (1 deficiency)

8 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2023-09-27 · Fire 2023-09-27

8 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

3 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 3 Health 2022-08-31 · Fire 2022-08-31

4 health deficiencies

Top issue: Resident Rights (2 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-06

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-11-18

F · Potential for more than minimal harm 2024-11-06

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-03-25

E · Potential for more than minimal harm 2024-11-06

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2024-12-18

E · Potential for more than minimal harm 2024-11-06

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-11-18

E · Potential for more than minimal harm 2024-11-06

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-11-18

E · Potential for more than minimal harm 2024-11-06

K751 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of flammable curtains.

Corrected 2024-11-18

E · Potential for more than minimal harm 2024-11-06

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2024-11-18

E · Potential for more than minimal harm 2024-11-06

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-11-18

D · Potential for more than minimal harm 2023-09-27

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-10-11

C · Minimal harm 2023-09-27

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-10-11

C · Minimal harm 2023-09-27

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-10-11

F · Potential for more than minimal harm 2022-08-31

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2022-10-14

F · Potential for more than minimal harm 2022-08-31

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-09-30

F · Potential for more than minimal harm 2022-08-31

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2022-09-02

F · Potential for more than minimal harm 2022-08-31

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2022-11-30

E · Potential for more than minimal harm 2022-08-31

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2022-11-30

E · Potential for more than minimal harm 2022-08-31

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2022-09-30

E · Potential for more than minimal harm 2022-08-31

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2022-09-02

D · Potential for more than minimal harm 2022-08-31

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2022-09-02

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-03-10

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-03-10

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-03-24

D · Potential for more than minimal harm 2024-12-18

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-01-07

F · Potential for more than minimal harm 2024-11-06

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-11-18

D · Potential for more than minimal harm 2024-11-06

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-11-18

J · Immediate jeopardy 2024-06-25

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-07-10

D · Potential for more than minimal harm 2024-06-25

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-07-10

D · Potential for more than minimal harm 2024-06-25

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-07-10

F · Potential for more than minimal harm 2023-09-27

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2023-10-20

F · Potential for more than minimal harm 2023-09-27

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-10-20

D · Potential for more than minimal harm 2023-09-27

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-10-20

D · Potential for more than minimal harm 2023-09-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-10-11

E · Potential for more than minimal harm 2022-08-31

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2022-09-23

D · Potential for more than minimal harm 2022-08-31

F551 · Resident Rights Deficiencies

Health

Give the resident's representative the ability to exercise the resident's rights.

Corrected 2022-10-14

D · Potential for more than minimal harm 2022-08-31

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2022-09-30

D · Potential for more than minimal harm 2022-08-31

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2022-09-01

Penalties and ownership

What sits behind the stars

$50,606 2024-06-25

Fine

Fine · fine $50,606

Fine

Ownership

Baier, Patricia

Operational/Managerial Control · Individual

0% 1 facilities 2016-01-01

Baier, Patricia

Corporate Director · Individual

0% 1 facilities 2016-01-01

Brasure, Ann

Operational/Managerial Control · Individual

0% 1 facilities 2024-01-01

Brasure, Ann

Corporate Officer · Individual

0% 1 facilities 2024-01-01

Crockford, Lynne

Operational/Managerial Control · Individual

0% 1 facilities 2020-01-01

Crockford, Lynne

Corporate Officer · Individual

0% 1 facilities 2020-01-01

Decker, Dan

Operational/Managerial Control · Individual

0% 1 facilities 2024-01-01

Decker, Dan

Corporate Officer · Individual

0% 1 facilities 2024-01-01

Ebli, Jim

Operational/Managerial Control · Individual

0% 1 facilities 2024-01-01

Ebli, Jim

Corporate Officer · Individual

0% 1 facilities 2024-01-01

First Bank Upper Michigan

5% Or Greater Mortgage Interest · Organization

0% 1 facilities 2022-11-30

Frantz, Lana

Operational/Managerial Control · Individual

0% 1 facilities 2016-01-01

Frantz, Lana

Corporate Director · Individual

0% 1 facilities 2016-01-01

Fredrick, Audrey

Operational/Managerial Control · Individual

0% 1 facilities 2024-01-01

Fredrick, Audrey

Corporate Director · Individual

0% 1 facilities 2024-01-01

Hayes, Paul

Operational/Managerial Control · Individual

0% 1 facilities 2021-01-01

Health Direct Institutional Pharmacy Services Inc

Operational/Managerial Control · Organization

0% 1 facilities 2018-06-01

Herriges, Rosemary

Operational/Managerial Control · Individual

0% 1 facilities 2021-01-01

Herriges, Rosemary

Corporate Director · Individual

0% 1 facilities 2016-01-01

Kaldor, Carrie

Operational/Managerial Control · Individual

0% 1 facilities 1999-01-01

Mattson, Ann

Operational/Managerial Control · Individual

0% 1 facilities 2024-01-01

Mattson, Ann

Corporate Director · Individual

0% 1 facilities 2024-01-01

Prime Time Healthcare LLC

Operational/Managerial Control · Organization

0% 6 facilities 2019-11-01

Pultz, Robert

Operational/Managerial Control · Individual

0% 1 facilities 2016-01-01

Pultz, Robert

Corporate Director · Individual

0% 1 facilities 2016-01-01

Sikora, Christy

Operational/Managerial Control · Individual

0% 1 facilities 2021-05-18

Up Rehab Services LLC

Operational/Managerial Control · Organization

0% 2 facilities 2018-06-01

Wipfli Llp

Operational/Managerial Control · Organization

0% 32 facilities 1999-01-01

Nearby options

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Optalis Health and Rehabilitation of Kingsford

Kingsford, MI

1-star overall rating with 1-star inspections with $139,667 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

Overall: 1 / 5
Health: 1 / 5
Staffing: 2 / 5
Fines: $139,667

#2